A Use of Force Review notes that “the situation may have been heightened by the number of staff that were outside the prisoner’s cell”. I second this view and would further note that segregation cells are small and claustrophobic. Crowding distressed women is unlikely to diffuse difficult situations. In yet another incident, a woman refusing to strip and wear a gown was handcuffed and held on the ground until she stated that she couldn’t breathe, at which stage “staff loosened their holds allowing her to sit back on her knees to open her chest and catch her breath”. “There was no suggestion, as far as I could see, of taking the woman to a hospital following her attempt on her life, or indeed providing her with pastoral care or just a cup of tea. Instead, six officers entered her small cell, physically restraining her when she refused to wear an anti-rip gown.” One woman was recorded as self-harming 23 times, 20 of which involved her tying something around her neck “until her face became purple”. Sixteen of her attempts on her life took place at the prison’s ISU. Another woman was routinely placed in waist restraints to prevent her from picking at her wounds. Other women banged their head against the cell wall, attempted to hang themselves, and scratched and cut themselves. Women who were clearly very unwell remained in the prison rather than being transferred to hospital. The records I reviewed did not reveal a culture of care and compassion towards women who self-harmed. Rather, further restraints and force often followed such attempts, further aggravating an already delicate situation. 46